In 1988, when he finished his internal medicine residency, John R. Nelson, MD, took a "temporary" job taking care of inpatients.
Now, 21 years later, Nelson directs the hospitalist program at Overlake Hospital in Bellevue, Washington, and is a national
practice consultant. And hospitalist work, a mere blip on the medical profession's radar in the late 1980s, is among medicine's
fastest growing specialties.
In the mid-1990s when the term "hospitalist" was first coined, fewer than 500 non-emergency medicine physicians confined themselves
to acute care settings. According to the Society of Hospital Medicine, the number of physicians who devote themselves primarily
to inpatient care is expected to reach 30,000 in 2010. Hospitalists are in almost 60 percent of U.S. hospitals.
Most hospitalists are certified in internal medicine; smaller percentages are family physicians or pediatricians. The American
Board of Internal Medicine and the American Board of Medical Specialties are working on a hospital medicine certification
program, which is likely to be ready in 2010-2011. Hospitalists are increasingly viewed as specialists who do inpatient medicine,
says Donna Knapp, chief operating officer of Sierra Hospitalists, a 20-physician practice in Reno, NV.
CHARACTERISTICS OF HOSPITAL MEDICINEWhat accounts for the rise of hospitalists? Internist Patrick J. Cawley, chief medical officer at the Medical University of
South Carolina, and immediate past president of the Society of Hospital Medicine, cites several reasons:
- Fewer primary care physicians are making hospital rounds, so they're turning inpatient care over to hospitalists.
- As the number of uninsured patients increases, so do the ranks of people who arrive in the hospital as "unassigned" patients.
Hospitalists admit these patients and tend to them.
- Hospitals are under pressure to improve patient care and shorten stays. Hospitalists are best equipped to do that.
- Hospitalists are cost-effective. A study published in the Dec. 20, 2007, New England Journal of Medicine indicates that hospitalists,
on average, reduced inpatient stays by 12 percent.
HOSPITAL MEDICINE VS. OUTPATIENT PRACTICE
"Becoming a hospitalist is like dating a practice, and joining an outpatient practice is more like marriage," says Nelson.
The former is characterized by interesting and ever-changing patient encounters, while the latter benefits from a long-term
commitment and relationships with patients. And a hospitalist's day is ruled by the pager, while a non-hospitalist's day is
ruled by the clock, Nelson says. Office doctors must try to see patients close to their scheduled appointment time. Hospitalists
aren't as constrained by a schedule.
Hospitalist practice, Cawley notes, is especially suitable for physicians who are comfortable in the hospital, who want to
see patients with acute medical issues, who don't mind working nights and weekends, and who can handle unpredictability. "If
you prefer a structured workday, you probably should stay in the office," Knapp says.
Hospitalists need to communicate with patients quickly and easily. "The responsibility to listen carefully may be greater
for hospitalists than for other types of physicians," says Knapp. "While primary care physicians most likely treat patients
they've seen several times, a hospitalist is almost always starting from scratch."
Any career has its drawbacks, of course. For hospitalists, these include trading long-term physician-patient relationships
for brief encounters. Moreover, because hospitalists typically are part of a team, they don't have the same autonomy as private
practice physicians.
According to many hospitalists and their advocates, however, the negatives are outweighed by the positives:
- Regular hours, allowing for a better work/life balance than outpatient doctoring.
- Overhead is usually a non-issue. Employers generally pay for hospitalists' malpractice insurance premiums.
- A hospitalist is busy from day 1. There's no need to spend years building a practice.
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